Section 1: Student Information
Student Name:___________________________________________________________________________ Student ID Number:_________________________
____________________________________________________________________________________________________________________________
Student Signature Date
FORM ID: F21IU REV:12.09.19
Section 2: Housing Status and Enrollment Information
Please indicate your intended housing and enrollment status for both the fall and spring semesters.
Fall 2020 Spring 2021
£ University Housing
£ Commuter (living with parent/relative)
£ O-Campus* (living in own apartment/home)
£ University Housing
£ Commuter (living with parent/relative)
£ O-Campus* (living in own apartment/home)
£ 12+ credits
£ 6–11 credits
£ 5 or less credits
£ Not enrolled
£ 12+ credits
£ 6–11 credits
£ 5 or less credits
£ Not enrolled
Expected graduation date: £ December £ April £ June £ August Year_________
Section 3: Additional Funding
Are you a dependent or spouse of a University of Pittsburgh employee? o Yes o No
Are you a dependent or spouse of a UPMC employee? o Yes o No
Does your employer reimburse all or a percentage of your tuition? o Yes o No
(Please provide an estimated amount in the grid below)
If you are the recipient of a scholarship or grant from a source outside of the University of Pittsburgh for the 2020-2021 academic year,
please indicate the source and the amount below. This includes private scholarships, OVR, EAP, and tuition reimbursements from any
employer. Attach additional sheet, if necessary.
Source Amount Check Term/Year
o Fall Only o Spring Only o Full Year
o Fall Only o Spring Only o Full Year
o Fall Only o Spring Only o Full Year
o Fall Only o Spring Only o Full Year
If you are receiving funding from an outside source, will the funding be issued directly to you the student? o Yes o
No
Section 4: Student Certication
o I will not attend the University of Pittsburgh during the 2020–21 academic year.
o Adjust Aid:
Type of Aid_________________ From $________ to $________ o Fall only o Spring only o Academic Year____
Type of Aid_________________ From $________ to $________ o Fall only o Spring only o Academic Year____
Type of Aid_________________ From $________ to $________ o Fall only o Spring only o Academic Year____
By Signing below:
• I certify that all of the information provided on this nancial aid acceptance form is true and complete to the best of my knowledge. If I
purposely give false or misleading information, the Financial Aid Oce has the right to cancel my nancial aid or to le a complaint with
the U.S. Department of Education’s Ombudsman or University of Pittsburgh’s Judicial Aairs Oce.
• I attest that I will use my nancial aid and/or any refund of my nancial aid for my educational-related expenses.
• I understand that if my nancial aid does not satisfy my balance due, I am responsible for the payment of the remaining debt.
• I am aware that I must immediately notify the Financial Aid Oce in writing of both the source and the amount of any outside funding
that I receive, and I understand that such awards may reduce my initial nancial aid package.
• I acknowledge that the Financial Aid Oce has the right, at any time, to reduce or cancel awards which I am no longer eligible to receive
or resolve awards in excess of need or the established cost of attendance.
2020
–
2021
INFORMATION UPDATE
Oce of Financial Aid
450 Schoolhouse Road
Johnstown, PA 15904
Phone: 814-269-7045
Phone: 800-881-5544
Fax: 814-269-7061
Email: upjaid@pitt.edu
